Nursing Intervention

Apply witch-hazel dressing to perianal area or anal creams or suppositories, if ordered, to relieve discomfort.

Observe anal area postoperatively for drainage and bleeding.

Administer stool softener or laxative to assist with bowel movements soon after surgery, to reduce risk of stricture.

Teach anal hygiene and measures to control moisture to prevent itching.

Encourage the patient to exercise regularly, follow a high fiber diet, and have an adequate fluid intake (8 to 10 glasses per day) to avoid straining and constipation, which predisposes to hemorrhoid formation.

Discharge and Home Healthcare Guidelines

Teach the patient the importance of a high-fiber diet, increased fluid intake, mild exercise, and regular bowel movements. Be sure the patient schedules a follow-up visit to the physician. Teach the patient which analgesic applications for local pain may be used. If the patient has had surgery, teach her or him to recognize signs of urinary retention, such as bladder distension and hemorrhage,and to contact the physician at their appearance.

Exam

MSN Exam for Hemorrhoids (PM)*

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Question 1

Client education should include minimizing client discomfort due to hemorrhoids. Nursing management should include:

A

Suggest to eat low roughage diet

B

Advise to wear silk undergarments

C

Avoid straining during defecation

D

Use of sitz bath for 30 minutes

Question 1 Explanation:

Straining can increase intra abdominal pressure. Health teachings also include: suggest to eat high roughage diet, wearing of cotton undergarments and use of sitz bath for 15 minutes.

Question 2

Which of the following factors would most likely be a primary cause of her hemorrhoids?

A

Her age

B

Three vaginal delivery pregnancies

C

Her job as a school teacher

D

Varicosities in the legs

Question 2 Explanation:

Hemorrhoids are associated with prolonged sitting, or standing, portal hypertension, chronic constipation and prolonged intra abdominal pressure as associated with pregnancy and the strain of vaginal delivery. Her job as a schoolteacher does not require prolong sitting or standing. Age and leg varicosities are not related to the development of hemorrhoids.

Question 3

The nurse is interviewing a male client about his past medical history. Which preexisting condition may lead the nurse to suspect that a client has colorectal cancer?

A

Duodenal ulcers

B

Hemorrhoids

C

Weight gain

D

Polyps

Question 3 Explanation:

Colorectal polyps are common with colon cancer. Duodenal ulcers and hemorrhoids aren’t preexisting conditions of colorectal cancer. Weight loss — not gain — is an indication of colorectal cancer.

Question 4

Nurse Nico instructs her client who has had a hemorrhoidectomy not to used sitz bath until at least 12 hours postoperatively to avoid which of the following complications?

A

Hemorrhage

B

Rectal Spasm

C

Urinary retention

D

Constipation

Question 4 Explanation:

Applying heat during the immediate postoperative period may cause hemorrhage at the surgical site. Moist heat may relieve rectal spasms after bowel movements. Urinary retention caused by reflex spasm may also be relieved by moist heat. Increasing fiber and fluid in the diet can help constipation.

Question 5

Which position would be ideal for the client in the early postoperative period after hemorrhoidectomy?

A

High Fowler’s

B

Supine

C

Side – lying

D

Trendelenburg’s

Question 5 Explanation:

Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side – lying are ideal from a comfort perspective. A high Fowler’s or supine position will place pressure on the operative site and is not recommended. There is no need for trendelenburg’s position.

Question 6

The doctor orders for Witch Hazel 5 %. Nurse Nico knows that the action of this astringent is:

causes coagulation (clumping) of proteins in the cells of the perianal skin or the lining of the anal canal

C

inhibits the growth of bacteria and other organisms

D

causes the outer layers of skin or other tissues to disintegrate

Question 6 Explanation:

Option a are local anesthetics; c are antiseptics and d are keratolytics.

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Nursing Care Plan

Nursing Care Plan for Hemorrhoids

Nursing Diagnosis

Impaired Tissue Integrity

May be related to

Hemorrhoidal surgery and procedures

Alteration in activity

Changes in mobility

Aging process

Loss of elasticity of skin

Possibly evidenced by

Disruption of skin tissue from incisional sites

Destruction of skin layers

Thrombosed hemorrhoids

Internal prolapsed hemorrhoids

Pain

Swelling

Drainage

Desired Outcomes

Patient will have intact skin with no signs or symptoms of rectal prolapse or bleeding.

Hemorrhoids will be reduced or removed.

Patient will exhibit no evidence of thrombosed hemorrhoids or rectal bleeding.

Patient will have normal CBC with no noted anemias.

Patient will be able to accurately verbalize understanding of causes of hemorrhoids, methods of preventing the worsening of hemorrhoids, and comfort measures to employ.

Swollen hemorrhoids will be reduced in size, with no pain evoked.

Patient will be able to tolerate procedures to diagnose problem and to treat hemorrhoids without the presence of any complication.

Nursing Interventions

Assess patient for presence of hemorrhoids, discomfort or pain associated with hemorrhoids, diet, fluid intake, and presence of constipation.

Rationale: Provides baseline information as to type of hemorrhoids (external or internal), degree of venous thrombosis, presence of complications, including bleeding, and risk factors that preclude patient to hemorrhoids to enable initiation of care plan appropriate for patient.

Administer topical medication as ordered.

Rationale: Reduces swelling, pain, and/or itching in order to make patient more comfortable.

Provide “donut cushion” for patient to sit on if needed.

Rationale: Hemorrhoids are exquisitely painful and patient may not be able to sit in chair and apply pressure to delicate tissues. Donut cushions can help remove pressure from the hemorrhoid; caution on the occurrence of pressure areas.

Administer stool softeners as ordered.

Rationale:Helps prevent straining and increases pressure that may cause clotted vessels to rupture or cause further hemorrhoids to develop. Helps relieve pain by avoiding passage of hard fecal material.

Assist with procedures for treatment of hemorrhoids.

Rationale:

Sclerotherapy may be used if problem is detected early, it involves injection of quinine urea hydrochloride or other agent into sclerosed vessels, with resultant swelling and dying of the vessel, with reabsorption within the body.

Banding the hemorrhoid may also be performed, this involves the application of a rubber band around the base of each hemorrhoid, which ultimately results in the death and necrosis of the hemorrhoid.

Laser surgery may also be performed but symptomatic relief is not obtained immediately.

Hemorrhoidectomy is performed if the patient has internal hemorrhoids with prolapse, or if the patient has both internal and external hemorrhoids. It relieves symptoms immediately but can create scar tissues and other complications; should be done as a last resort.

Instruct patient and/or family regarding causes of hemorrhoids, methods of avoiding hemorrhoids, and treatments that can be performed.

Rationale: Hemorrhoids are caused by straining, heavy lifting, obesity, pregnancy, and any activity that distends rectal veins and causes them to prolapse.

Instruct patient and/or family regarding all procedures required.

Rationale: Internal hemorrhoids are normally diagnosed by anoscopy or flexible sigmoidoscopy because digital rectal exam cannot adequately detect hemorrhoids. Barium enemas or colonoscopy may be required to ensure that intestinal masses are not presence as well.

Instruct patient and/or family in dietary management.

Rationale: Increasing bulk, fiber, fluids, and eating fruits and vegetables can help by maintaining soft stools to avoid straining at bowel movements.

Instruct patient and/or family regarding the use of bulk producing agents, such as psyllium husk.

Nursing Interventions

Rationale: Assists with identification of an effective bowel regimen and/or impairment, and need for assistance. GI function may be decreased as a result of decreased digestion. Functional impairment related to muscular weakness and immobility may result in decreased abdominal peristalsis and difficulty with identification of the urge to defecate.

Instruct patient or SO in deep breathing, relaxation techniques, guided imagery, massage and other nonpharmacologic aids.

Rationale: Helps patient to focus less on pain, and may improve efficacy of analgesics by decreasing muscle tension.

Instruct patient or SO regarding use of acetaminophen and to avoid use of aspirin.

Rationale: Acetaminophen may relieve pain and headache, but should be used cautiously in patients with liver dysfunction because of acetaminophen metabolism in the liver. Aspirin can potentially cause hemorrhage and ulceration, therefore, must be avoided.